LEC 5.2: Nursing Process | Assessment

Assessment

Systematic and continuous collection, organization, validation, and documentation of data

Continuous process carried out during all phases of the nursing process

Focuses on a client’s responses to a health problem

Should indicate the client’s perceived needs, health problems, related experience, health practices, values, and lifestyles

To be most useful, the data collected should be relevant to a particular health problem

(1) collection

(2) organization

(3) validation

(4) documentation

Assessment is the systematic and continuous (1) ____, (2) ___, (3) ____, and (4) ___ of data

(1) all

Assessment is a continuous process carried our during (1) ___ phases of the nursing process

(1) responses

Assessment focuses on a client’s (1) ____ to a health problem

(1) perceived needs

(2) health problem

(3) related experience

(4) practices, values, and lifestyles

Assessment should indicate the client’s (1) ___ ___, (2) ___ ___, (3) ___ ___, health (4) ___, ___, and ___

(1) relevant

In Assessment, to be most useful, the data collected should be (1) ___ to a particular health problem.

2008 Joint Commission

Who stated that each client should have an initial nursing assessment consisting of a history and physical examination performed and documented within 24 hours of admission?

24 hours

According to the 2008 Joint Commission, within how many hours of admission does an initial nursing assessment need to be conducted?

Licensed Practical Nurse (LPN)

According to the 2008 Joint Commission, aside from the RN, who may gather data for the initial nursing assessment?

Registered Nurse (RN)

According to the 2008 Joint Commission, who is responsible for the following:

• care,

• must assess the data to determine client needs, and

• develop the client’s plan of care

1. Initial Nursing Assessment

2. Problem-Focused Assessment

3. Emergency Assessment

4. Time-Lapsed Reassessment

4 Types of Assessment

Initial Nursing Assessment

One of the types of assessment

Performed within specified time after admission to a health care agency

Purpose is to establish a complete database for problem identification, reference, and future comparison

Nursing Admission Assessment (a form upon the arrival of patient)

Example of an Initial Nursing Assessment

Problem-Focused Assessment

One of the types of assessment

On-going process integrated with nursing care

To determine the status of a specific problem identified in an earlier assessment

Hourly Assessment

Example of a Problem-Focused Assessment

Emergency Assessment

One of the types of assessment

Performed during any physiological or psychological crisis of the client

To identify life-threatening problems and identify new or overlooked problems

Rapid Assessment of a Patient Having Cardiac Arrest

Example of an Emergency Assessment

Time-Lapsed Reassessment

One of the types of assessment

Done several months after initial assessment

To compare the client’s current status to baseline data previously obtained

Reassessment of a Client’s Functional Health Problems

Example of a Time-Lapsed Reassessment

Data Collection

Process of gathering information about client’s health status

Should be systematic and continuous

Database

Contains all information about the client

1. Nursing Health History

2. Physical Assessment

3. Primary Care Provider’s History & Physical Information

4. Laboratory & Diagnostic Test Results

5. Material Contributed by Other Health Personnel

What does the Database include?

1. Subjective Data

2. Objective Data

2 Types of Data

Subjective Data

One of the types of data

Symptoms or covert data that only the affected person can describe and verify

symptoms; covert

Subjective data are ___ or ___ data.

Objective Data

One of the types of data

Signs or overt data detectable by an observer

Can be seen, heard, felt, smelled and obtained by observation or physical examination

signs; overt

Objective data are ___ or ___ data.

1. Client (Primary)

2. Support People

3. Client Records

4. Health Care Professionals

5. Literature

5 Sources of Data

Client (Primary)

One of the sources of data

Usually the best source of data

Unless too ill, young, or confused to communicate

Support People

One of the sources of data

Includes family members, friends, and caregivers who know the client well

Especially important for a client who is young, unconscious, or confused

Authorized first, especially is client is mentally able

Client Records

One of the sources of data

Information documented by various health care professionals

Reviewing it allows nurses to avoid previously answered questions

Medical Records, Records of Therapies, Laboratory Records

Examples of Client Records (a type of Data Source)

Health Care Professionals

One of the sources of data

Doctors for example

Literature

One of the sources of data

Examples include professional journals and reference texts

1. Observation

2. Interview

3. Examining

3 Data Collection Methods

Observation

One of the data collection methods

Gather data using the senses

Must be organized so nothing is missed

Interview

One of the data collection methods

Planned communication or a conversation with a purpose

Examining

One of the data collection methods

A systematic collection of data that uses observation to detect health problems

Uses apparatus

Uses the technique of inspection, auscultation, palpation, percussion (IAPP)

(1) organized systematically

All assessment data should be (1) ___ ___.

Gordon’s Functional Health Patterns

What is an example of Organizing Data?

Validating Data

Act of double-checking or verifying data to confirm that it is accurate and factual

Nurse’ assumptions are verified or further questioning may be prompt

Asking a patient “Is it correct you gave 5 births?” instead of repeating the question “How many births have you given?”

What is an example of Validating Data?

1. Ensure assessment information is complete

2. Ensure that objective and subjective data agree

3. Obtain additional information that may have been overlooked

4. Differentiate between cues and inferences

5. Avoids jumping to conclusions

What 5 tasks does Validating Data help the nurse complete?

Cues

Part of the tasks that Validating Data helps the nurse complete

Subjective or objective data that can be observed

Inferences

Part of the tasks that Validating Data helps the nurse complete

Interpretation made based on cues

Cue: Grimacing

Inference: Pain

Example of a cue and an inference

Documenting Data

Recording of client’s data

Should include all data collected about the client’s health status

Should be factual rather than interpreted by the nurse